Early Intervention for Autism Spectrum Disorder

Jun 26, 2017 10:11AM
● By Digital Media Director

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By: Virginia Olson and Alex Strauss

According to the most recent data from the
Centers for Disease Control and Prevention, one in 68 children is diagnosed
with Autism Spectrum Disorder (ASD) – up from 150 in 2002. ASD is now the
diagnostic category listed in the DSM-V to describe a group of developmental
disorders encompassing a range of symptoms and levels of disability.

Characteristics of ASD include delays in the
development of communication skills and vocabulary, problems in building
relationships, and being socially withdrawn. Symptoms often appear at an early
age. Babies and toddlers with autism spend less time looking at people, are
less responsive when their names are called, and often fail to develop gestures
such as pointing, which are important to set the stage for language. By the
time they enter school, these tendencies can cause serious problems in learning
and social interaction.

Experts now say that therapeutic intervention as
early as possible may be the key to mitigating the effects of ASD and
maximizing these children’s potential.

LifeScape, a long–time regional leader in
providing services to people with disabilities and their families, is offering innovative and evidence-based new
options for earlier ASD intervention. Depending on their unique situation, a
child who has been diagnosed with ASD as early as 12 months of age can now
receive multidisciplinary therapy through Early and Intensive Behavioral
Intervention (EIBI) or through a new approach called the Early Start Denver
Model (ESDM). Both models utilize principles of Applied Behavior Analysis
(ABA).

Early and
Intensive Behavioral Intervention

In their 2014 book, Comprehensive Guide to Autism, authors Lars Klintwall and Svein
Eikeseth describe Early and Intensive Behavioral Intervention (EIBI) as “an
evidence-based intervention which uses principles and procedures from Applied
Behavior Analysis to teach adaptive behaviors to young children with ASD.”

Vicki Isler, Ed.D, BCBA-D, DIrector of
Residential and Education Services at LifeScape, has decades of experience with
ABA therapy. She says the tenets on which it is based are relatively simple and
universally applicable. “Behavior that is reinforced will happen again. This
goes for all of us, whether or not a person has autism.”

Although ABA can be used with any age group, as
Klintwall and Eikeseth observe, the approach appears to be especially effective
when applied early (ideally before age 5) and intensely (30 to 40 hours of
therapy per week). A 2014 analysis of EIBI published in Research in Developmental Disabilities found that, among toddlers
with autism who entered the therapy program before their second birthday, 90
percent made significant gains. While all children in the study gained from the
therapy, the percentages gradually dropped the older a child was when they
entered therapy.

“From the time the pediatrician can say there is
a developmental delay, we can begin to work with them,” says Isler. Although
the therapy has not been covered by insurance in South Dakota (which will be
changing soon - see below), Isler has seen the impact of EIBI in her former
state of Florida. “Many of these children, if you can get them into therapy
early enough, can go into school without even showing symptoms of autism.”

Delivered under the direction of Board Certified
Behavior Analysts (BCBAs), the EIBI approach consists of identifying which
skills the young child lacks, breaking these skills into component parts, and
then working on each of these components separately, repeating and rewarding as
needed until the child has mastered each step in a sequence and can perform the
task independently.

“For some reason, children with autism don’t
learn by observation and imitation the way other children do. They have to be
taught every little thing,” says Isler. “So we use these ABA principles to
teach them to follow simple directions, including things they need to do to get
ready for preschool such as sitting still, paying attention, and imitating.
Then we work on numbers and colors. We teach this all in a very structured
way.”

In the EIBI approach, the environment is
carefully structured to so that the child is most likely to be successful at
acquiring and maintaining new skills. Repeatedly practicing (and receiving
reinforcement for) novel skills in a structured setting prior to using them in
a natural setting, is one of the key pieces of an EIBI package. EIBI uses
one-on-one discrete training for basic skills and may include less structured
teaching for skills like self-care.

EIBI Soon to Be
More Accessible

Despite significant research supporting the
benefits of EIBI, and although South Dakota has long had BCBAs capable of
providing it, the therapy has not been covered by insurance, making it
completely inaccessible for many South Dakota families who might benefit.
Unlike physical therapy that may be effectively delivered in weekly one-hour
visits, EIBI can require up to 40 hours a week and cost as much as $40,000 a
year. As a result, at LifeScape, ABA
therapy has been largely restricted to the inpatient population where the
school district helps foot the bill.

But thanks to the efforts of parents, therapists,
and other advocates, South Dakota became the 39th state to mandate insurance
coverage for therapy for ASD in 2015, with the provision that BCBAs must be
licensed by the state, just as occupational therapists or physical therapists
currently are. Isler worked on a committee to write the new rules for licensing
BCBAs, who will be licensed under the state Board of Social Work. She
anticipates that all of the state’s BCBAs will have the opportunity to become licensed
by the end of the year and begin billing insurance companies for their
services.

“For years, we have known that early, intensive
intervention is what many of these children

needed,” says speech language
pathologist Megan Wiessner, MA, CCC-SLP, part of LifeScape’s Autism Evaluation
Team. “But without having the coverage from insurance, although we have
recommended this to parents for years, most just couldn’t pay out of pocket for
it.”

Under the new law, children with autism will be
eligible to receive ABA services through the age of 18. It allows for up to
$36,000 a year to cover ABA therapy for children ages 0 to six, $25,000 for
children seven to 13, and $12,500 for those 14 to 18.

The Early Start
Denver Model

Another option for young children with
ASD in our region is The Early Start Denver Model (ESDM), a comprehensive
behavioral early intervention approach for children with autism from 12 to 48
months.

An adaptation of the of the Denver Model
preschool originally developed in the 1980s, ESDM utilizes a curriculum that
includes ABA principles and addresses skills across all domains of development
- fine and gross motor, communication, joint attention, activities of daily
living, etc. - to provide a multidisciplinary approach for very young children
and their families. The ESDM can be used in various delivery settings and
utilizes a “naturalistic approach” to increase a child’s interest in activities
and other people.

“ESDM is a naturalistic developmental
behavioral intervention model that takes principles of ABA therapy as well as
knowledge of children’s typical development and fuses them together into a
curriculum and an approach that any discipline can use,” says Wiessner.
“Instead of working one-to-one at a table with an adult, we work on goals within
natural activities. It might be a game or an art project or a snack. We embed
things like requesting, eye contact, imitation, or vocalization. It is a nice
comprehensive option for these little kiddos.”

With ASD diagnosis now possible in younger patients,
Wiessner says the goal is to teach these small children what they need to know
to succeed by the time they start school. “It is now possible to help children
as young as a year old and we have the tools to diagnose most children by the
age of two,” says Wiessner. “Even a handful of years ago children often weren’t
diagnosed until eight, nine or ten.” By that time, many were already
experiencing problems in school.

Although the ESDM approach is new to the area,
the research on this emerging therapy looks promising says Megan Johnke, OTD,
OTR/L, Director of Therapy at LifeScape.

A randomized controlled trial of ESDM published
in the journal Pediatrics in 2010
suggested that children who received ESDM therapy for 20 hours a week over two
years showed more improvement in their cognitive and language skills, more
adaptive behaviors, and fewer autism symptoms than a control group of children
who received a variety of other community-based services. The research prompted
Time Magazine to name ESDM to its list
of top ten medical breakthroughs in 2012 and the approach is sanctioned by the
American Academy of Pediatrics.

“LifeScape has been providing speech,
occupational therapy and psychological services for a long time,” says Johnke.
“ESDM is just more collaborative for a well-rounded approach.”

LifeScape has taken a lead role in helping its
personnel become certified in this new approach to early ASD intervention.
Wiessner, who will attend her advanced ESDM training in November, may be the
first to receive this certification in South Dakota. Several other LifeScape therapists are
currently training in the ESDM curriculum.

Intervention
Starts with Evaluation

Regardless of which therapeutic path a child
ultimately takes, Sioux Falls child and adolescent psychiatrist David Ermer,
MD, part of LifeScape’s Autism Evaluation Team, says the first step is
professional evaluation. Erner recommends that any child exhibiting early signs
of ASD be referred to the autism team for testing, especially if parents have
concerns.

“There is no harm in making the referral,” says
Dr. Ermer. “The harmful thing could be waiting too long because early
intervention is so important. The earlier you intervene and start getting help
for the child, the better things are likely to go in the school setting, at
home, in social settings, and later on.”

Dr. Ermer says he has seen for himself the
positive impact that early behavioral intervention can make.

“I have seen some tremendous differences in
children who have gotten help from someone who is highly trained and follows
the established guidelines,” he says. “In some cases, I have been able to
either stop prescribed medicines or not have to prescribe them at all because
things have improved so much. When in doubt, refer on.”

“The thing I love about this is that severe
behavior is fixable,” adds Isler. “if a child comes in on a ventilator, I can’t
do anything about that. But if they come in hitting, kicking, biting and
throwing things, I can fix that. You can make a real impact with early intervention.”